Tophaceous gout — SCE Rheumatology MCQ

Correct answer: D — Escalate allopurinol using monthly urate measurements, aim below 300 µmol/L, and discuss colchicine prophylaxis

Explanation lettering: C = shown as A · E = shown as B · B = shown as C · A = shown as E

The persistent tophi are the key discriminator. Although his serum urate is below the standard target of 360 µmol/L and he is currently flare-free, NICE advises considering a lower target below 300 µmol/L in people with tophi or chronic gouty arthritis. His repeated measurements remain above that target, so treatment has not yet reached its disease-modifying goal. Allopurinol should therefore be titrated further, guided by monthly serum urate measurements and tolerability. A 300 mg daily dose is not a universal maximum; licensed doses may be titrated substantially higher when clinically appropriate. The benefits and risks of flare prophylaxis should be discussed during titration, with colchicine offered if he chooses prophylaxis. A applies the usual target but overlooks the lower target appropriate for tophaceous disease; annual monitoring is appropriate only after the individual target has been achieved. B is incorrect because absence of recent flares does not indicate crystal clearance, and gout usually requires long-term urate-lowering therapy. C is premature: febuxostat is a reasonable alternative if allopurinol is not tolerated or the target cannot be achieved with appropriate titration, but 300 mg is not the maximum dose. E may suppress flares but does not correct the residual urate burden; colchicine is an adjunct during urate-lowering titration, not a substitute for achieving target urate.

Reference: Gout: diagnosis and management (NG219) — Recommendations (9 June 2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations Allopurinol Tablets 100 mg — Summary of Product Characteristics (18 November 2025) — https://www.medicines.org.uk/emc/product/14283/smpc